**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to activate their emergency response system by calling 911 and immediately initiating Cardiopulmonary Resuscitation (CPR) for 1 of 3 residents reviewed who were full-code and were found unresponsive and without respirations and a heart rate (Resident #82), in accordance with the American Heart Association and the Basic Life Support (BLS) for Healthcare Providers. Resident #82 was a full-code status and had requested aggressive life-saving treatment despite medical decline. The resident was last seen on [DATE] at 7:58 AM, by the nurse who took vital signs, administered blood pressure medications, and left the resident in stable condition. On [DATE] at approximately 8:40 AM, the resident was found unresponsive by the Registered Dietician (RD) who immediately alerted the Licensed Practical Nurse (LPN) who in response had a Certified Nursing Aide (CNA) accompany her to the resident's room. The resident was found unresponsive laying slumped over in bed. The LPN documented she began to panic and shake [him/her] and checked vital signs. The LPN later asked the CNA to help reposition the resident. The LPN proceeded to call the Physician and the family member on the telephone. The LPN while on the computer, noticed the resident was a full code status and went into full blown panic mode, and went back to the room to start CPR and the [family member] walked in the room to ask what was doing, and said to stop. The LPN proceeded to not administer CPR against the resident's code status request. The LPN left the room and the Licensed Nursing Home Administrator (LNHA) asked if the LPN called 911 in which she responded no. According to documentation, the facility never initiated CPR, called 911, or accessed the automated external defibrillator (AED; a device used to deliver an electric shock to the heart to restore heart rhythm) in an attempt to provide life-saving measures. Resident #82 was pronounced dead at 10:04 AM, by a physician [name redacted]; cause was an unexpected death. The LPN was terminated from employment at the facility and survey team attempted to reach the nurse multiple times by telephone for an interview and were unsuccessful. There was no documented evidence a Code Blue (a signal used to communicate an acute medical emergency) was initiated, or that CPR, or 911 was activated upon becoming aware resident was unresponsive. According to NN on [DATE], 911 was not called until 9:10 AM. There was no documented evidence once paramedics arrived that the resident was evaluated for intubation, or the use of the AED. Interview with the Director of Nursing (DON) on [DATE] revealed all nurses were certified in CPR, so there was always someone in the facility that could perform CPR. The DON provided a copy of the LPN's valid CPR certification. The facility's failure to appropriately initiate CPR and the appropriate activation of emergency response (including calling 911) for a resident who was a full-code and was found to be unresponsive without a heart rate and respirations, placed all residents who were a full-code at risk for imminent death if found to be unresponsive without a pulse and without respirations. This resulted in an Immediate Jeopardy situation. The Immediate Jeopardy (IJ) began on [DATE] at 8:40 AM, when the resident was found unresponsive and ran until [DATE] after in-services of staff began, and the LPN was terminated at 3:00 PM. The IJ was Past Non-Compliance. The facility was notified of the Past Non-Compliance IJ situation on [DATE] at 3:51 PM. The facility was back in compliance when they addressed this situation by calling 911; suspending and then terminating the LPN upon investigation; all staff were in-serviced on code-status; when to initiate CPR; documentation in an emergency situation and communication with nursing management; performed a mock code; and in-serviced all Agency staff on facility policy. The evidence was as follows: Reference: The American Heart Association (AHA) 2010 . guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations . In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when cardiac or respiratory arrest occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid Do Not Resuscitate (DNR) order is in place; 2) obvious clinical signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. On [DATE] at 9:17 AM, the surveyor reviewed the closed medical record for Resident #82 who had expired in the facility. A review of the admission Record face sheet reflected the resident was admitted to the facility in December of 2022 with diagnoses which included malignant neoplasm of hypopharynx and retromolar area (cancer of the throat and oral cavity), diabetes, pancytopenia (a reduction in all three major cellular elements of blood), essential (primary) hypertension (high blood pressure). A review of the Admission/readmission Evaluation dated [DATE] at 12:45 PM, reflected the resident was alert and oriented to person, place, and time with clear speech. A review of the Order Summary Report (OSR) included a physician's order (PO) dated [DATE], for full code status. A review of the Progress Notes (PN) for Resident #82 which included the following notes: A Nursing Note (NN) dated [DATE] at 6:30 AM, written by the resident's 11:00 PM to 7:00 AM shift Registered Nurse (RN), included the resident was toileted three times during this shift; alert and verbally responsive; blood sugar done and coverage given as ordered; left comfortable in bed, call bell with-in reach; no signs or symptoms of pain or discomfort noted. A Health Status Note (HSN) dated [DATE] at 9:08 AM, written by the LPN, revealed the resident had expired around 8:45 AM; feeding tube (a tube inserted through the wall of the abdomen into the stomach which can be used to give medications or liquids) disconnected; the resident was bathed and growned by nurse and CNA; family member called spoke with [name redacted] explained the situation and he/she hung up the phone; Physician notified. A NN dated [DATE] at 9:10 AM, written by the Infection Preventionist/LPN (IP/LPN), revealed upon entering this building this nurse was called to resident's room; resident was noted with no blood pressure or no pulse; 911 called immediately as resident was a full code. A NN dated [DATE] at 10:10 AM, written by the IP/LPN, included paramedics on scene; no blood pressure or heart rate maintained; resident was pronounced by physician [name redacted] at 10:04 AM with family at bedside. There was no documented evidence that 911 was called at the time the resident was found non-responsive; CPR was immediately initiated or initiated at all; or a AED was used. On [DATE] at 9:33 AM, the surveyor attempted to call the LPN on the telephone, a male party answered, the surveyor stated his/her name and the purpose of the call, and the call was disconnected. The surveyor placed the call again, there was no answer, and the surveyor left a message on the voicemail to please return the call as soon as possible. LPN did not return surveyor's call. On [DATE] at 9:40 AM, the surveyor interviewed the IP/LPN who stated Resident #82 had been admitted to the facility for rehabilitation; was very sickly and expired at the facility. She further stated she was not in the building when the situation occurred on [DATE], she walked into the building with the paramedic arriving right after. On [DATE] at 10:19 AM, the surveyor interviewed the DON who stated she was familiar with Resident #82 that he/she had been at the facility for a short term, had cancer, and was ailing. She further stated the resident had expired at the facility and had been taken care of that day by an Agency Nurse (LPN). The DON stated she had interviewed the LPN who stated she had been flustered and had gone into the room; she tried to get his/her code status; left the room and called the Physician and family member; and then she called 911; she did not start CPR. When the surveyor asked the DON what the facility's procedure was when you find a resident unresponsive, she responded when you find someone unresponsive, you should call the code, then call 911. The DON stated she did have a copy of the LPN's witness statement; she conducted an investigation. On [DATE] at 10:35 AM, the DON provided the surveyor with the LPN's statement dated [DATE], which indicated the nurse was assigned to the resident that morning. The resident was seen during rounds with their feeding tube running; they took vital signs; preformed mouth care; and administered medication for their blood pressure of 150/99. The resident was alert and did not verbalize any discomfort, no facial grimacing, and breathing unlabored. Around 8:40 AM, the RD informed her the resident was slumped over leaning in their bed. The LPN stated she rushed to the resident's room with the CNA and noted the resident was slumped over and non-responsive. The LPN began to panic and she shook the resident and took vital signs, but there was no pulse. The LPN asked the CNA to get the DON, and the CNA informed them they were coming. The LPN reported being so flustered trying to think what to do. The LPN called the Physician and then called the resident's family member. When on the computer, the LPN noticed the resident was a full-code and went into full blown panic mode, and she went back into the room to start CPR. The family member was in the room at this time and did not want me to start CPR. The LPN left the room to give them privacy and saw the LNHA who asked if 911 was called. The LPN stated no and proceeded to call 911. On [DATE] at 10:54 AM, the surveyor interviewed the DON in the presence of the survey team. When the surveyor asked where the code status of a resident can be found, the DON replied all residents' code statuses were located in the electronic medical record on the opening screen; as well as a hard copy was included on the physician's orders which were printed monthly and placed in the residents' hard charts. The DON stated the facility also had a backup system for recalling a few hours of information if the electricity or electronic medical record were unavailable. The DON stated that the CNAs had access to residents' code statuses in their task manager. The DON stated she was not in the building at the time of Resident #82's death, but stated every nurse should know they should call a code if the resident was unresponsive and begin CPR if applicable. The DON stated she also thought the problem was the family member told the LPN to stop CPR when the LPN tried to initiate it. When asked if the family had the authority to stop the CPR, the DON stated I do not know. On [DATE] at 11:08 AM, the DON stated the family member was not the Power of Attorney (POA; authority to make decisions on behalf of another) so therefore would not have the authority to cease CPR. On [DATE] at 11:49 AM, the surveyor interviewed the RD in the presence of the survey team. The RD stated she came into Resident #82's room early in the morning, maybe between 8:00 AM and 8:05 AM, and the resident was turned onto his/her side and belly and feeding tube was on administering enteral formula, and the formula appeared to be spilled on the floor. The RD stated she called out the resident's name, he/she did not respond, so she then got the LPN immediately. The LPN went to the room called his/her name, and the RD left the room as the CNA closed the door behind them. On [DATE] at 12:01 PM, the surveyor attempted to interview the CNA via telephone, she did not answer, and surveyor left voicemail to return the call. On [DATE] at 12:22 PM, the surveyor attempted to call the LPN again, surveyor left another message to call back. LPN did not return surveyor's call. On [DATE] at 1:09 PM, the DON provided the survey team a copy of the facility's Incident Investigation Summary for Resident #82. On [DATE] at 1:13 PM, the surveyor interviewed resident's Physician and Medical Director (MD) in the presence of the survey team. The MD stated he evaluated the residents and reviewed the medications and other paperwork on admission to the facility, one of those would be code status. If the resident had a Practitioner Orders for Life Sustaining Treatment (POLST; a form that specifies the type of medical treatments a person wants to receive during serious illness) form, it would be reviewed, and he would make a physician's order for the code status. The MD stated full-code status meant everything should be done, CPR started, 911 called and advanced life support as well with use of an AED. The MD stated CPR should be started immediately if a person had no pulse or respirations, then immediately tell a staff member to call a code, then follow protocol of airway and breathing, and circulation. The staff member would continue CPR until paramedics arrived to take over. When asked if a family member could stop CPR, the MD replied only if the family member was the medical POA could they authorize staff to stop CPR. At this time, the surveyor reviewed the LPN's statement with the MD who confirmed 911 and CPR should have been first. The MD also stated the patient was always first, not notifying the Physician or family, and the nurse should never leave a resident during a code. On [DATE] at 1:59 PM, the survey team interviewed the DON, who confirmed Resident #82 was a full code status which meant the resident wanted all treatments to revive them including being sent to the hospital. The DON continued if staff walked into a room and a resident was unresponsive, they must call a code; tell another staff to call 911 because you should never leave the resident alone; start CPR; have another staff member grab the crash cart which contained the AED and oxygen. The DON further stated all nurses who worked in the facility were certified in CPR, so there was always someone in the facility that could administer CPR, and staff should continue administering CPR until paramedics arrive to take over. The DON stated the LPN stated she had been flustered, and confirmed she did not call the code so 911 was not immediately called and CPR was not immediately initiated. The DON also stated the family member did not have the authority to stop CPR so the LPN should have initiated it. The DON stated the facility conducted an investigation to determine why the LPN who was an Agency Nurse did not call the code. The DON stated she informed the LPN's Agency that the facility did not want her back because of her incompetency. On [DATE] at 2:21 PM, the surveyor reviewed LPN's witness statement to the DON who stated disregard the LPN's Progress Note which indicated the resident was expired at 8:45 AM, the resident was pronounced dead at 10:04 AM after the paramedics arrived. The DON confirmed the LPN had not acted in accordance with professional standards of practice in regard to following resident's code status preference. On [DATE] at 2:41 PM, the survey team interviewed the LNHA who stated he had worked [DATE], and stated while in building, saw the LPN in the hallway outside of Resident #82's room and the LPN made him aware the resident was found unresponsive. The LNHA asked the code status which he was told was full-code, so he asked if the LPN if she called 911. The LNHA stated the LPN stated no and instructed her to call. The LNHA stated as a result of their conversation the LPN called 911, but he did not recall when the paramedics arrived. The LNHA further stated there were no other nurses helping the LPN when he was there. The facility's failure to ensure the appropriate activation of emergency response for a resident who was a full-code status by calling 911 and initiating CPR when the resident was found to be unresponsive without a heart rate and respirations, placed all residents who were a full code at risk for imminent death if found to be unresponsive without a pulse and without respirations. This resulted in an Immediate Jeopardy situation. The IJ was identified on [DATE], and the LNHA and DON were notified of the IJ at 3:51 PM. The IJ was a Past Non-Compliance IJ that ran from [DATE] at 8:40 AM, when Resident #82 was found unresponsive to [DATE] at 10:04 AM, when the paramedics arrived and pronounced the resident dead. The facility was back in compliance when they addressed this situation by immediately suspending the LPN upon investigation which led to her termination; in-servicing of all staff on emergency situations including CPR; a mock code performed with all staff; and in-servicing of all Agency nurses as scheduled on facility process. This was verified by the survey team on-site on [DATE]. On [DATE] at 7:46 AM, the surveyor interviewed the CNA assigned to Resident #82 on [DATE] via telephone. The CNA stated she was in another resident's room performing care down the hall and she went into the hallway to retrieve supplies when the LPN called her to come to Resident #82's room. The CNA stated she went into the room and the resident was not responding; the LPN shook him/her; checked the pulse, resident's stomach, and ankles; and rubbed their sternum. The LPN then instructed her to get the DON, who was not in the building, and she immediately returned to the LPN to let her know. The CNA confirmed she did not inform any other staff members; she just did what she was told to do by the LPN. The LPN then instructed her to help clean-up the resident. When asked what clean-up meant, the CNA stated the resident was soiled so they changed their incontinent brief and shorts putting the resident in a gown. The CNA stated the resident's top portion of his/her body was folded over and their knees were on the ground as if they rolled over; it did not appear as if the resident fell. The CNA stated that the LPN did not tell her if the resident had a pulse, but stated the resident did not look alive to her. The CNA stated she did not recall the LPN calling a Code Blue and the LPN did not perform CPR. The CNA further stated anyone can call a code; that she assumed the nurse did not call the code because she was already aware of the resident's code status. The CNA stated she was CPR certified, but also did not initiate CPR. A review of the facility's Incident Investigation Summary included a copy of the LPN's CPR certification. The LPN had a CPR Adult, child, infant and AED training valid from [DATE] until [DATE]. A review of the facility provided daily staffing sheet for [DATE] revealed on the day shift from 7:00 AM until 3:00 PM, there were four nurses assigned to work and eight CNAs assigned to work that day. A review of the facility's Code Blue or Code Status Process policy dated effective [DATE] and revised [DATE], included a Code Blue is the standardized signal used to indicate any acute medical emergency (i.e. respiratory distress, reduced function due to arrhythmia, cardiac arrest or status epilepticus). Every individual whose vital signs are not life sustaining or unobtainable is a candidate for resuscitation unless there has been written patient care wishes to withhold treatment and an existing order in place. It is the responsibility of the licensed nurse to check for the status code order .the first responder is the staff member who discovers an unresponsive individual. The will: call for help - call out to other staff members .He or she stays with the individual .Administer assistance to level of their expertise. Verify unresponsive, absence of respirations or absence of pulse and start CPR if trained .The second responder should be a staff member trained in BLS. They will: alert the receptionist to call Code Blue .bring the crash cart to the Code location. The third responder will be responsible for calling 911 .monitor and assist with CPR if required . NJAC 8:39-9.6(g)